DOs a natural fit for physical medicine and rehabilitation

Mutual attraction characterizes the relationship between the specialty and osteopathic physicians.

Despite the limited number of AOA-approved residency programs in physical medicine and rehabilitation—two in New York, one in Michigan and one in Florida—osteopathic physicians have been making a big impact on this small but rapidly growing specialty. In fact, 23% of current residents in allopathic PM&R programs are DOs.

Mutual attraction characterizes the relationship between the specialty and DOs. Requiring a whole-patient approach to care, excellent communication skills and an understanding of the interrelationship of structure and function, PM&R has many of the same expectations and training emphases as osteopathic medicine. Because manual medicine is one of the main interventions used in PM&R, the specialty draws osteopathic medical students serious about osteopathic manipulative treatment. In turn, many of the 79 PM&R residency programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) find DO graduates to be especially well-prepared.

The median annual pay for PM&R physicians, commonly called physiatrists, is close to $240,000, putting it in the mid-range for medical specialties. But tremendous variation exists in compensation for physiatrists, depending on practice type and subspecialty, says Christina A. Richardson, DO, the president of the American Osteopathic College of Physical Medicine and Rehabilitation (AOCPMR).

More than money, however, other lifestyle factors lure roughly equal numbers of men and women into the field. Physiatrists generally work reasonable hours. “A lot of practices don’t take call or the call that they take is very minimal and is shared among a large group of physiatrists,” notes Dr. Richardson, who practices in Traverse City, Mich.

More important, the specialty can be deeply fulfilling. “The fundamental premise that function and structure are interrelated and both can be modified is simplistically beautiful,” observes John R. Carbon Jr., DO, of Warwick, R.I., who trained in the Sinai-Johns Hopkins PM&R program in Baltimore in the late 1990s. “The ability to get a post-stroke hemiplegic to walk is not only fascinating but rewarding, as is the ability to ease the adverse affects of spondylosis without spinal surgery or strong medications.”

With the primary goal of improving function and promoting independence, physiatrists treat patients who have all manner of disabilities, chronic diseases and impairments—from spinal cord injuries, brain injuries and limb amputations to cerebral palsy, multiple sclerosis and amyotrophic lateral sclerosis. Many PM&R physicians subspecialize in sports medicine and pain medicine, while some focus on patients with specific conditions and limitations. Physiatrists practice in hospitals, rehabilitation centers and outpatient settings and sometimes pursue careers in academia.

The breadth of the specialty appeals to J. Michael Wieting, DO, a professor of PM&R and the dean of clinical medicine at the Lincoln Memorial University-DeBusk College of Osteopathic Medicine in Harrogate, Tenn. “I wanted a specialty in which I could see a mixture of patients in an outpatient setting, where I could develop long-term relationships with many patients but also see some patients in the short term on a consulting basis,” says Dr. Wieting, who has practiced PM&R for more than 25 years. “I also wanted to treat patients of all ages. In my practice right now, patients range in age from 8 to older than 90. I love that.”

In Dr. Richardson’s view, PM&R brings together some of the most exciting and cognitively challenging aspects of many different specialties. “It was my interest in musculoskeletal medicine that first drew me to a rotation in PM&R. But through that rotation, I discovered that some of my other loves were also part of this field,” she explains. “I liked the trauma of emergency medicine, but I wanted to be able to follow up and know what was going on with patients afterward. I liked the puzzles that neurology offered. I liked the complexity of internal medicine. And I liked the diagnostics of orthopedics. Physiatry is an amalgam of all of these fields.”

Doubling in size from approximately 5,000 to 10,000 physiatrists in the past 20 years, the specialty offers many career opportunities. PM&R will continue to grow in demand as the population ages and requires more rehabilitative services for chronic disease management, musculoskeletal dysfunction, neurologic impairment and chronic pain.

The right stuff

Exceptional interpersonal skills are a must for anyone contemplating a career in physical medicine and rehabilitation. “Rehab medicine attracts very outgoing, very personable individuals who really like to engage with their patients,” Dr. Richardson says. “We tend to follow people for many years, even decades.”

Besides establishing long-term relationships with patients, physiatrists must be skilled at working with emotionally vulnerable populations. “In rehab medicine, we are helping people in the darkest moments of their lives in many cases,” Dr. Richardson explains. “We are there for some of the lowest of the lows and the highest of the highs. It takes a special person to be part of that process.”

Dr. Carbon notes that physiatrists tend to be down-to-earth individuals who communicate with patients using common language, not medical jargon. For example, he says, to advise a patient to quit smoking, “a physiatrist might well say, ‘Dylan, you’re still smoking two packs of butts a day? Are you nuts?’ ”

Physiatrists frequently touch patients and not just during physical examinations and manipulation. “In a typical interaction with a patient, a physiatrist will say, ‘I will hold you here, and I want you to push against me as hard as you can,’ ” Dr. Carbon notes.

In addition, PM&R specialists often demonstrate the rehab exercises they recommend. “A physiatrist might explain, ‘This is how to use a wall for stretching your calf muscles—watch,’ ” says Dr. Carbon.

“Those who are timid or afraid of ‘getting dirty’ should not get into PM&R,” Dr. Carbon warns.

Physiatrists also must be team players and leaders who excel at care coordination. “We are trained to work with physical therapists, occupational therapists, psychologists and speech therapists, using their skills in addition to our own clinical acumen and hands-on skills to guide patients through the rehabilitation process,” says Leonard B. Kamen, DO, the AOCPMR’s vice president.

Because PM&R patients commonly are involved in workers’ compensation cases, lawsuits, automobile accidents involving more than one insurance carrier, and other complex legal tangles, physiatrists need to be able to effectively argue a cause or a case, Dr. Carbon points out.

While PM&R specialists need to be smart, resourcefulness and creativity matter more than memorization and test-taking skills. “One of the tools I carried around with me as a resident in Baltimore was a shoehorn,” Dr. Carbon remembers. “I used it more than a stethoscope. It came in quite handy when I examined feet, assessing sensation, muscles, skin vascularity and gait. Without it, I wouldn’t have been able to get patients’ shoes back on.”

Competitive edge

More than 800 osteopathic medical students currently are involved in the AOCPMR’s campus chapters. Student members can participate in clinical workshops sponsored by the society to gain exposure to PM&R diagnostic techniques, such as nerve conduction studies and musculoskeletal ultrasound. In conjunction with the AOCPMR’s midyear meeting, students can take part in a national student conference that provides the chance to meet with PM&R educators, program directors and residents.

“We’ve had hundreds of osteopathic medical students from all over the country attend our two major annual conferences,” Dr. Kamen says. “There is tremendous student interest in our field.”

“We find that the students who are interested in going into PM&R tend to be extremely well-informed,” Dr. Richardson adds. “They are so focused, so driven, so goal-oriented and such strong supporters of not just PM&R as a profession but also the osteopathic world in general.”

Because of its desirability, PM&R is a moderately competitive specialty. For example, each year approximately 300 students apply for 12 positions in the ACGME-accredited Temple University-MossRehab Hospital PM&R residency program in Philadelphia. “We interview 60 candidates,” says Dr. Kamen, a preceptor in the program. “So you need to have good credentials to get that far.”

Osteopathic PM&R physicians by state

More than 800 DOs specialize in physical medicine and rehabilitation.

(Source: AOA)

PM&R residency candidates need to have at least average scores on the Comprehensive Osteopathic Medical Licensing Examination—USA or the United States Medical Licensing Examination. Because interest in the field is growing, high examination scores can make a candidate stand out among well-qualified peers, Dr. Richardson says.

A former program director for Michigan State University’s dually accredited PM&R residency program, Dr. Wieting offers a number of tips to students interested in becoming physiatrists:

Get involved in organizations that provide services to people with disabilities. Students can serve as counselors in summer camps for children and adults with physical or developmental disabilities, and they can participate in fund-raising events for United Cerebral Palsy, the Muscular Dystrophy Association and similar organizations.

Participate in research projects to gain an understanding of the research process because every PM&R resident must complete a scholarly project.

Dr. Wieting encourages PM&R candidates to participate in both the AOA Intern/Resident Registration Program and the National Resident Matching Program (NRMP) but not to rank any program they wouldn’t want to take part in. Because the AOA and the NRMP do not have a joint match, any candidate who matches into an AOA-approved PM&R program must pull out of the allopathic match.

Training and certification

PM&R offers two training paths. Traditionally, osteopathic medical students would serve a rotating internship and then complete a three-year PM&R residency. While this option is still available, many graduates today head right into a four-year PM&R program.

“I’m a big supporter of the rotating internship because you will get experience you will never get again in your career and you’ll be exposed to things that will be helpful in your residency,” says Dr. Richardson, who trained at the Rehabilitation Institute of Chicago and was among the eight out of 12 residents who served a rotating internship. “For example, a dermatology rotation will help you understand the rashes that you will see among rehab patients.”

Dr. Richardson cautions students to be familiar with the requirements of any states they might practice in. Certain states require osteopathic physicians to have served osteopathic internships.

Beyond residency, many physiatrists also serve fellowships or obtain certificates of added qualification in subspecialties such as pain management, pediatric rehabilitation and traumatic brain injury.

“A DO who goes through an allopathic PM&R residency program and wants to become AOA board-certified simply has to contact the AOBPMR, fill out the application, send in documentation of training, pay a fee and sit for the exam,” Dr. Wieting says.

DOs who are interested in becoming osteopathic residency program directors, deans of osteopathic medical schools or AOA leaders must be AOA board-certified.

PM&R versus OMM

DO physiatrists commonly use OMT, but manipulation isn’t necessarily their main approach to treating patients. “If you want to have your primary approach to patients be OMT, then I’d recommend becoming an osteopathic manipulative medicine specialist who is AOA board-certified in neuromusculoskeletal medicine,” Dr. Wieting suggests. “If you want OMT part of your armamentarium but not the principal part, then PM&R is a good way to go.”

Still, the similarities between PM&R and OMM are striking. “PM&R is a specialty that requires a physician, even an MD, to think exactly like every DO is taught to think from the beginning of medical school,” Dr. Wieting says. “Every PM&R doctor must think about a patient from a functional standpoint and a holistic standpoint.

“Physiatrists have to deal with not only the diagnosis but also how that diagnosis affects the patient’s function and interactions at home, in the community and on the job.”

In addition, physiatrists develop highly individualized treatment plans. “What I need to accomplish to get one stroke patient home may be very different from what I need to do to get another person with the exact same kind of stroke home because of differences in family support, the patients’ occupations and comorbidities,” Dr. Wieting explains. “PM&R is a specialty that requires physicians to think osteopathically every day with every patient.”

5 comments

Deja Vu

It is the enhanced diagnostic abilities of the neuromusculoskeletal training and less the OMT treatment skills that create the finer physiatrists. Imagine the advantage DO’s have in an allopathic residency with their osteopathic gait analysis skills that very few MD residents ever even skimmed over. The tissue palpating experience for finding spasm and trigger points and integrating that information relative to somato-visceral patient pathologies as well.